Access, Cost, and Quality for APRNs
Healthcare quality is a broad term that encompasses various dimensions and concepts. Due to the ambiguities associated with defining care quality, healthcare professionals are responsible for measuring healthcare performance by using multiple quality indicators and performance metrics. According to the Agency for Healthcare Research and Quality [AHRQ] (2022), the Institute of Medicine (IOM) established an influential framework for defining and measuring care quality. This model entails six primary aims of healthcare systems, including safety, care effectiveness, patient-centeredness, timeliness, efficiency, and equity. Amidst intricacies in the current healthcare systems and the demand for quality care, healthcare professionals strive for greater autonomy in their practice and control over their work environment. In this sense, independent practice laws enable advanced practice registered nurses (APRNs) to maximize client care and enhance problem-solving skills consistent with the overarching objectives of ensuring care access, affordability, and quality. Amidst the benefits of safeguarding autonomy for APRNs, it is valid to argue that care access, costs, and quality are interrelated concepts whose measures and evaluation influence the role development of advanced practice registered nurses.
Access, Cost, Quality of Quality Environments, and Recent Quality Initiatives
Care accessibility is a profound dimension of care quality since it entails having the opportunities for timely use of personal health services to achieve the desired health outcomes. According to Toscos et al. (2018), access to care consists of three primary aspects and steps: achieving entry into the healthcare system, obtaining access to timely and essential care services, and locating providers that meet individual health needs, priorities, and preferences. Equally, Toscos et al. (2018) contend that effective communication during care provision and the subsequent development of meaningful, respectful, and trusting relationships between healthcare professionals and patient populations are vital aspects of care accessibility. Although access to timely and efficient care is a fundamental dimension of care quality, healthcare professionals encounter complexities in bridging chasms and addressing the underlying factors that compromise people’s access to quality care.
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Social determinants of health (SDOH) are the primary causes of disproportionate access to quality and timely healthcare services. Islam (2019) defines social determinants of health as “conditions or circumstances in which people are born, grow, live, work, and age” (p. 1). For example, nutrition, education levels, employment, built environment, neighborhood factors like pollution, and sociocultural contexts determine people’s utilization of healthcare services. In this sense, people grappling with unemployment, a lack of proximal healthcare facilities, low-level education attainment, poor housing, constraining sociocultural issues, and poverty are highly likely to encounter health disparities and limited access to quality care (Islam, 2019). Advanced practice registered nurses (APRNs) are responsible for spearheading initiatives aimed at addressing these unfavorable social determinants of health to promote care accessibility and eliminate barriers to care utilization among vulnerable communities and populations.
Care affordability is a precursor to service accessibility since it entails consumers’ ability to pay for the delivered services. In this context, patients are the primary consumers of healthcare services and must pay for the rendered services to sustain the healthcare system. According to Shrank et al. (2021), Americans should have access to affordable healthcare despite unsustainable growth of healthcare expenditures. Consequently, the country has enacted various healthcare policies to curtail the ever-upsurging cost of healthcare services. Shrank et al. (2021) argue that the implementation of the Affordable Care Act (ACA) in 2010 has significantly slowed the unsustainable health expenditures in the US by expanding insurance coverage to accommodate people struggling with poverty, low income, and other issues, including disabilities. When considering how the US government invests massively in the healthcare system to reduce the cost burden, it is vital to note that consumers must get the value of the insurance plans, as well as out-of-pocket payment. Therefore, using cost as a performance metric can enable healthcare professionals to evaluate the performance of the healthcare system.
It is possible to define the quality environment of the current healthcare system by using the six dimensions of quality care. According to Girouard et al. (2018), care access, cost, and quality are the profound aspects that underpin the triangle structure of the quality environment. Often, access to care and services affordability are the primary factors for health equity. In this sense, they contribute to preventable disparities that are disproportionate to people of a specific ethnicity, socioeconomic status, gender, sexual orientation, and geographical aspects. Although access to quality and affordable care is a human right rather than a privilege, the prevailing social determinants of health are the major causes of health inequalities. For example, underinsured and uninsured people have limited access to healthcare services since they cannot afford insurance premiums and out-of-pocket expenses (Perreira et al., 2021). As a result, the need to cover at-risk populations and address disparities in care accessibility and affordability motivates health policies in the United States. For example, the Medicaid expansion policy under the Affordable Care Act (ACA) aimed at increasing insurance coverage by accommodating previously excluded sections of the consumer population. Such policies are vital in creating a quality environment for care delivery.
Current Quality Initiatives
Quality improvement initiatives focus on enhancing organizational structures, processes, and outcomes to curtail care costs, improve care quality, and bolster access to efficient, effective, and timely care services. According to Hill et al. (2020), continuous quality improvement in healthcare entails adopting systematic data-guided activities, interactive development and testing processes, and designing localized interventions for identifying problems and informing improvement opportunities. Healthcare professionals in the current healthcare systems use various models to spearhead quality improvement initiatives.
For instance, the PDSA (Plan-Do-Study-Act) framework is a profound model that allows organizations to identify issues, develop response and improvement plans, study these plans through evaluation, and act accordingly to sustain quality improvement initiatives. Knudsen et al. (2019) contend that the key methodological approaches and features of the PDSA model are the use of continuous data collection procedures, developing a theoretical rationale for quality improvement initiatives, and small-scale testing. These features support the adaptation of health projects to specific contexts and minimize the unintended consequences of quality improvement projects. Examples of current quality improvement initiatives that prompt the need for the PDSA model are the reduction of medication errors and related adverse events, the implementation of electronic health records and other advanced technologies, and the prevention of preventable hospital readmissions.
The Relationship Between Quality Measures, Evaluation, and Role Development
Quality measures, evaluation, and role development are interrelated concepts that underpin the role of advanced practice registered nurses (APRNs). According to the American Nurses Association [ANA] (2017), APRNs play a forefront role in treating and diagnosing illnesses, managing chronic diseases, educating the public on health issues and concerns, and incorporating technological, methodological, and other developments consistent with the need for ongoing professional development. Besides these roles, APRNs understand the intricacies and demands in the current healthcare systems by using their experience and reputable academic knowledge. However, they must frequently evaluate organizational factors to ensure that they provide quality care.
Quality measures encompass tools for measuring and quantifying processes, outcomes, and organizational structures pertinent to care delivery. The Donabedian model requires healthcare professionals to assess and compare the quality of healthcare organizations based on structural, process, and outcomes measures. These measures narrow down to the seven elements of quality of medical care, including efficacy, efficiency, equity, optimality, legitimacy, acceptability, and effectiveness (Ameh et al., 2017). Examples of outcomes measures are surgical complications, hospital-acquired infections, and surgical mortality rates. On the other hand, structural metrics include staff-to-patient ratios and the presence of advanced technologies like electronic medical records. Finally, process measures include the pain management approaches, the number of people receiving preventive care, and the number of blood sugar tests conducted on people diagnosed with diabetes. Undeniably, assessing organizational structures, processes, and care outcomes allow healthcare professionals to benchmark and compare their institutions with top-performing facilities in a specific specialty. As a result, the evaluation process forms the basis of quality improvement initiatives and the subsequent development of APRN roles to enhance care quality and outcomes.
How the Role of the Advanced Practice Registered Nurse (APRN) Change Without Effective Quality Measures
The absence of structural, process, and outcome metrics can significantly compromise the role of advanced practice registered nurses (APRNs). It is essential to note that APRNs apply different technological, methodological, and data-driven developments to thrive in ever-dynamic healthcare fields (American Nurses Association, 2017). Quality measures are ideal sources of data and information regarding organizational performance. For example, identifying the percentage of people with diabetes who have received blood sugar tests and the presence of advanced technological systems can provide insights into the facility’s infrastructural and procedural deficiencies. APRNs can use these data sets to initiate quality improvement initiatives and strengthen their leadership role in initiating, implementing, and sustaining change. As a result, the absence and access to ineffective quality measures deprive them of the opportunities to develop their leadership competencies, as well as limit the scope of quality improvement initiatives. Also, ineffective quality measures can lead to failures and a lack of accountability for advanced practice registered nurses, affecting the quality of care.
Advanced practice registered nurses (APRNs) play a significant role in promoting quality care. Their roles are dependent on data-driven practices, technological, and methodological approaches for professional development. It is essential to note that outcome, process, and structural metrics provide information regarding organizational performance and alignment to the dimensions of care quality. As a result, APRNs can fulfill and strengthen their roles by using these measures as tools for benchmarking and informing quality improvement initiatives.
Agency for Healthcare Research and Quality. (2022). Six domains of health care quality. https://www.ahrq.gov/talkingquality/measures/six-domains.html
Ameh, S., Gómez-Olivé, F. X., Kahn, K., Tollman, S. M., & Klipstein-Grobusch, K. (2017). Relationships between structure, process and outcome to assess quality of integrated chronic disease management in a rural South African setting: Applying a structural equation model. BMC Health Services Research, 17(1). https://doi.org/10.1186/s12913-017-2177-4
American Nurses Association. (2017, October 19). Advanced Practice Registered Nurses (APRN). https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/aprn/#
Girouard. S, DiFusco. A, & Jennas. J. (2018). Measuring advanced practice nurse performance: Outcome indicators, models of evaluation, and the issue of value. In J. Lucille A (Ed.). Advanced practice nursing: essential for role development (pp.366-386). Philadelphia, Pennsylvania: F.A. Davis Company
Hill, J. E., Stephani, A.-M., Sapple, P., & Clegg, A. J. (2020). The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: A systematic review. Implementation Science, 15(1). https://doi.org/10.1186/s13012-020-0975-2
Islam, M. M. (2019). Social determinants of health and related inequalities: Confusion and implications. Frontiers in Public Health, 7(11), 1–4. https://doi.org/10.3389/fpubh.2019.00011
Knudsen, S. V., Laursen, H. V. B., Johnsen, S. P., Bartels, P. D., Ehlers, L. H., & Mainz, J. (2019). Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-4482-6
Perreira, K. M., Allen, C. D., & Oberlander, J. (2021). Access to health insurance and health care for Hispanic children in the United States. The ANNALS of the American Academy of Political and Social Science, 696(1), 223–244. https://doi.org/10.1177/00027162211050007
Shrank, W. H., DeParle, N.-A., Gottlieb, S., Jain, S. H., Orszag, P., Powers, B. W., & Wilensky, G. R. (2021). Health costs and financing: Challenges and strategies for a new administration. Health Affairs, 40(2), 235–242. https://doi.org/10.1377/hlthaff.2020.01560
Toscos, T., Carpenter, M., Flanagan, M., Kunjan, K., & Doebbeling, B. N. (2018). Identifying successful practices to overcome access to care challenges in community health centers. Health Services Research and Managerial Epidemiology, 5, 233339281774340. https://doi.org/10.1177/2333392817743406
Discuss the access, cost, and quality of quality environments, as well as recent quality initiatives (See Chapter 24 and Table 24.1 of Joel, L.A., (2018). Advanced practice nursing. Essentials for role development (4th Ed.). Philadelphia, PA: F.A. Davis. [ISBN-13: 978-0-8036-6044-1]). Student is to reflect on the relationship between quality measures and evaluation and role development. In addition, describe this relationship and note how the role of the APN might change without effective quality measures.
- Length: 1500 words, double-spaced, excluding title and reference pages (required)
- Format: APA 7th Edition
- Describe the value, quality, and accountability context surrounding advanced practice registered nurse (APRN) practice.
- Understand APRN performance expectations in general and those specific to specialty practice.
- Develop quality and performance measures for use in practice at the individual, group, systems, and societal levels.
- Demonstrate the ability to design a model for assessing structures, processes, and outcomes within a framework of national standards.
- Plan actions to enhance the APRN impact in patient care, education, research, administration, and advocacy or policy.
- Chapter 24 • Measuring Advanced Practice Nurse Performance 367